Healthcare Provider Details

I. General information

NPI: 1629934823
Provider Name (Legal Business Name): MIND-BODY THERAPEUTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2025
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86B MARTIN LN
MORIARTY NM
87035-5605
US

IV. Provider business mailing address

86B MARTIN LN
MORIARTY NM
87035-5605
US

V. Phone/Fax

Practice location:
  • Phone: 505-895-3483
  • Fax: 715-504-8663
Mailing address:
  • Phone: 505-895-3483
  • Fax: 715-504-8663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JULIE ANN WILSON
Title or Position: OWNER
Credential: LPCC
Phone: 505-895-3484